Must I accept Medical Aid Limitations?

October 14, 2017

Is it obligatory to accept medical aid limitations?

  1. Coverage levels and exclusions depend on the choices you make
  2. Nore expensive policies carry higher coverage levels, and come at a higher price
  3. Less expensive coverage comes with limitations
  4. It is important to remember that coverage levels vary between plans
  5. You will almost always be responsible for co-pays and deductibles

 

Medical aids of South Africa are supposed to help their members enjoy good health care service at reasonable costs. You want a scheme you can rely on! Medical schemes typically cover:

  • Day-to-day benefits – out-of-hospital services and visits to  the doctor
  • Major medical expenses for hospitalisation
  • Maternity benefits
  • Chronic and acute medicines
  • Physical deficiencies

 

When it comes to medical aid, medical schemes offer various benefit plans. Members choose between hospital plans those hospital plans with a savings component. These can be comprehensive plans or network plans.

Medical aid members often discover that, in spite of the massive premiums they pay each month, there are limitations.

What’s on Offer in South Africa?

South Africa has a dual healthcare system, made up of public and private providers. Significantly, rich folks and members of medical schemes use private hospitals.

And even though these medical aids are regulated by the Medical Schemes Act (1998) and claim to be non-profit organisations, their limitations and exclusions cause doubt with members.

Evaluate your State of Health

Before choosing a medical aid, evaluate your state of health and needs and then decide on what you can afford.  Make sure you know if you are limited to a specific network of hospitals. You need to be aware of other limitations.

If your scheme for instance covers you at the normal 100% rate, you will have to negotiate tariffs with providers and if these charge you more than the medical aid tariff, you will have to pay in the difference out of your own pocket.

Limitations of Medical Schemes in South AfricaYes, hikes in healthcare have made it necessary for medical aids to put up members’ premiums at rates which are higher than general inflation, and they then try to reduce their benefits to make ends meet. This leads to misunderstandings and frustration with members.

Exclusions and Limitations on Certain Conditions

Medical aids try to limit their liability with exclusions on cover for certain conditions or treatments. Of course, the medical aid has to show that there is good reason for these exclusions and limitations. They are appropriate where they allow a degree of financial risk management but are inappropriate when essential healthcare isn’t important.

Most schemes for instance don’t include obesity management in their cover, and many medical aid members with this debilitating condition don’t think this is fair.

Every scheme’s hospital plans as well as their comprehensive medical aid plans will have unique levels of cover- and limits. You have to find out what the limits are before you sign up with any medical scheme.

Selfmed makes a point of being a medical scheme you can count on to simply explain complicated medical aid aspects. Why not call them and let one of their friendly, knowledgeable consultants bring clarity to some of your queries?

All info was correct at time of publishing